Review of "The Clinical Science of Suicide Prevention"

By Herbert Hendin and J. John Mann, (Editors)New York Academy of Sciences, 2001Review by Lou Gallagher, Ph.D. on Dec 1st 2004

The Clinical Science of Suicide
Prevention was the result of a conference entitled Suicide Prevention 2000
that was held on May 7-8, 2000 in New York City. Reading this compendium of
fourteen chapters written by the presenters at that conference leaves this
reviewer with the desire to attend the next conference that is held by the
American Foundation for Suicide Prevention, as this work is a "must-read"
for all mental health professionals.

Suicide and suicide attempts
represent a major cause of mortality and morbidity that disproportionably
affect several segments of American society: persons with serious and
persistent mental illness such as Schizophrenia, Mood and Depressive disorders
and Borderline Personality Disorder; the elderly and youths and adolescents.

Part I is comprised of six papers
that address the Diagnostic and Clinical Considerations that clinicians need to
consider, presenting a wealth of information and food for thought. The
assessment of the depressed suicidal patient addresses the risk factors that
increase the individual's proclivity for self harm. Interestingly, the
treatment regimes of Lithium for persons with Bipolar Disorder and Clozaril for
Schizophrenia result in a lower than expected risk of suicide, perhaps as the
authors conclude, that the medication monitoring of patients using these
medications provides increased clinical attention and earlier interventions in
addition to the drug benefits. The treatment of substance abusing individuals
as a high-risk group for suicidality, given the common comorbidity of mood
disorders, psychoses, personality and anxiety is another noteworthy chapter
that includes a description of several studies that appear to have promising
results in the treatment of these patients. The roles of psychotherapy and
pharmacotherapy with substance abusers point out the need for clinicians to
adopt and integrate a number of strategies for treatment to be successful.
Borderline Personality Disorders and the increased risk of self-mutilation
inherent with this population calls not only for an understanding that their
risk of suicide that is 400 percent that of the general population and 800
times that of females in general; but a greater examination of the mechanisms
that underlie the biological basis of self-mutilation. For these individuals,
Dialectic Behavior Therapy displays a promising treatment option that deserves
further consideration. A very important contribution to understanding suicide
risk pertains to the contribution that anxiety and impulsivity make to the
process of moving from ideation to action among persons at risk for suicide;
and, the need to address these factors as treatment conditions that can have an
effect upon suicidal behaviors.

Part II presents two seminal papers
regarding two age groups at opposite ends of the spectrum who are most at risk
for suicide: the elderly and youths. Following a review of the success and
failures of a number of treatment modalities among youthful patients, the
recommendation is made that a combined approach that involves the treatment of
the psychopathology; cognitive distortions and difficulties with social skills,
problem solving and affect regulation; with family education and intervention
appears to have the greatest therapeutic impact. Seventy percent of elderly
persons who commit suicide have seen their primary care physician in the month
prior to their demise. Physicians and other professionals who can learn and
recognize the depressive illness that may be present among their elderly
patients may have a unique opportunity to prevent suicides among this
population. The problems of living alone, recent losses both physical and
social, restricted openness to new experiences, physical illness and the
changes associated with reduced participation in familiar activities represent
high risk factors that, if addressed, may reduce the loss of these members of
society.

Although Part III is specifically
targeted for psychodynamically-oriented providers who may find themselves
dealing with individuals at-risk for suicide, the lessons learned may be of use
to all providers of mental health services regardless of orientation. As a
cognitive-behaviorist, this Part offered a great deal of information that may
be included as part of a thorough checklist of therapist cognitions when
assessing the thinking patterns associated with the persons we treat. The first
of the two papers presented addresses the factors of the psychodynamic paradigm
that interferes with the ability to diagnose and treat suicidally-depressed
individuals, concluding "the dynamically-oriented physician must use the
dynamic model of the mind when appropriate and recognize that in certain
situations it is not germane." The adoption of non-dynamic models in their
treatment may uniquely enhance the psychodynamic clinician to develop an
effective treatment plan for this group of persons in treatment with them. The
second paper provides assistance by describing a number of ways that the
psychodynamic therapist may adapt their treatment to more effectively deal with
the psychopathology of suicidal patients, particularly those who present with
narcissistic character disorders. Overall, the major cautionary note is that
treatment providers need to be aware that patients may deny, with therapist's
permission due to their own aversion of self-inflicted harm, that they are
actively suicidal so as to avoid interventions that will deny their desire for
self-termination.

Recognition of suicide crisis and
the timing of hospitalization of suicidal patients constitute Part IV. Suicide
crisis, defined as a time-limited period of immediate danger of self-harm is
distinguished from suicidal risk, defined as the probability that the person
may, at a given point in the future, make an attempt on their life. Three
factors are identified in the first paper in this part as markers of suicidal
crisis: a precipitating event; one or more affective states other than
depression; and at least one of three behavioral patterns: speech or actions
suggesting suicide, deterioration in social or occupational functioning; and,
increased substance abuse.

The second paper of this section
addresses the critical decision of determining whether a patient needs
immediate hospitalized, bearing in mind not only the general risk factors in
their background, such as older white males residing alone, prior suicide
attempts, substance abuse and a family history of suicide attempts/successes,
but present indicators such as command hallucinations, medical conditions,
anxiety, aggression and personality disorders (Borderline and Antisocial). The
author cogently warns that trusting persons in suicidal crisis to
self-transport or family members who may be manipulated into diversions is a
menu for disaster.

The final section, Part V, presents
two papers regarding the effects of the media following a suicidal incident and
the contribution of firearms to suicide risk. The presence of a gun in the home,
particularly among youthful individuals with a high level of impulsivity based
upon their lack of cognitive development, is one of the strongest predictors of
suicide, regardless of psychological disorders that may, and in many instances
in the general population, may not be a subject of treatment. Finally, the
effects of media coverage of successful suicides and attempts for the past two
decades in the United States and other countries has indicated a strong
correlation between prominent, frequent and sensational coverage and increases
in suicidal behaviors, particularly among youth. Most promising is the adoption
of media guidelines by Austria, written by mental health professionals, that
has been shown to have a significant impact upon reducing suicides in that
country.

Following each of the articles is a
discussion between the presenters and the moderators of the conference. These
discussions further clarify and expand upon the information presented within
that chapter, leading to further contemplation regarding the subject matter. This
reviewer suggests that providers, researchers, and administrators of mental
health and criminal justice programs that find themselves involved with the nationwide
transinstitutionalization of persons with severe and persistent mental illness
due to the closure of state-operated psychiatric facilities interested in
further information contact the American Foundation for Suicide Prevention at www.afsp.org, not only to remain current but to
enhance their proactive responses to suicide.

Lou Gallagher, Ph.D. Education:
B.A. in Psychology from Hofstra University, M.S. Ed. (with Distinction) in
Vocational Rehabilitation Counseling from Hofstra University, M.A. in
School-Community Psychology from Hofstra University, Ph.D. in Clinical and
School-Community Psychology from Hofstra University. Dr. Gallagher is a Fellow
of the American College of Forensic Examiners. He is a NYS Certified School
Psychologist and Licensed Psychologist, with training at the Institute for
Rational Emotive Therapy in the early 1980's. He has taught Psychology at Hofstra
University, Long Island University and other institutions in the past. He has
served for nineteen years as a Supervising Psychologist with the Suffolk County
Division of Community Mental Hygiene Services where he currently supervises a
number of community-based programs to divert persons with serious and
persistent mental illness (SPMI) from the criminal justice systems; provide
services to SPMI individuals being released from and within correctional
facilities; and, coordinates disaster mental health services and the Mental
Health Response Team, in addition to serving as the inoculated mental health
responder for the Suffolk County Smallpox Response Team. He has been in private
practice as a consulting and clinical Psychologist for twenty-one years, with
an emphasis upon anxiety disorders, depressive disorders, developmental
disabilities and Aspergers Syndrome and forensic issues.